Victrelis (Boceprevir) Prior Authorization Of Benefits (Pab) Form
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2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Victrelis (boceprevir)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: __________________________________
Prescribing Physician: ____________________________
Patient ID #:
__________________________________
Physician Address:
_____________________________
Patient DOB: __________________________________
Physician Phone #:
_____________________________
Date of Rx:
__________________________________
Physician Fax #:
_____________________________
Patient Phone #: _______________________________
Physician Specialty:
____________________________
Patient Email Address: ___________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
□
Victrelis (boceprevir)
______________________
Specify: _________________
200mg
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
□
□
Yes
No
Patient has access to sufficient quantity to complete an entire course of therapy
□
□
Yes
No
Patient is 18 years of age or older
□
□
Yes
No
Patient has a documented diagnosis of chronic Hepatitis C virus (HCV) Genotype 1 (documentation
may include, but is not limited to, chart notes, prescription claims records, prescription receipts, and
laboratory data)
□
□
Yes
No
A copy of the baseline quantitative HCV RNA test result has been provided to document baseline
level of viremia
□
□
Yes
No
Patient is using Victrelis (boceprevir) in combination with peg interferon alfa and ribavirin
□
□
Yes
No
Patient has compensated liver disease (with or without cirrhosis)
□
□
Yes
No
Patient will receive treatment with peg interferon and ribavirin for 4 weeks (Treatment Weeks 1-4)
prior to starting therapy with Victrelis
□
□
Yes
No
Patient is using Victrelis (boceprevir) in combination with another serine NS3/4A protease inhibitor, a
NS5B polymerase inhibitor, or a NS5A inhibitor
□
□
Yes
No
Patient has received previous treatment for hepatitis C virus (HCV) with one of the following (please
indicate):
□
An interferon-based triple therapy regimen, which includes ribavirin and an oral direct-acting
antiviral [such as but not limited to, Incivek (telaprevir), Victrelis (boceprevir), Olysio (simeprevir),
or Sovaldi (sofosbuvir)]
□
A therapy regimen containing a NS5A inhibitor [such as but not limited to, Harvoni
(ledipasvir/sofosbuvir) or ombitasvir)]
□
A therapy regimen containing a serine NS3/4A protease inhibitor [such as but not limited to,
Incivek (telaprevir), Victrelis (boceprevir), Olysio (simeprevir), or asunaprevir]
□
A therapy regimen containing a NS5B polymerase inhibitor [such as but not limited to Sovaldi
(sofosbuvir) or dasabuvir]
PAGE 1 OF 2, CONTINUED ON PAGE 2
Victrelis NTL PAB Fax Form 04.23.15.doc
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